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f - - APPLICATION FOR PERMIT , SAN JOAQUIN 'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 ]PERMIT EXPIRES 1-YEAR FROM DATE ISSUEDt` (Complete in Triplicate) ° t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is l made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Wui, �. � LL '... Job Address ,, oS6 City TG A L v of S,ze .b_V,�Z6p^ pM Owner's Name Y= Address .i d,�,6r?14 `=Phone Contractor Address Phone / s License No. �9�s`Fr�- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SeECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca aDia. of Well Excavationi Dia..of Well Casing D Domestic/Private --[J'Gravel-Pack"#--,❑-TracY --—T-ype-of-Casing-❑ Public ElOther LJDelta�T,} ----Specification -, Depth of;Grout Seal Type of Grout s 171 Irrigation _.-Approx. Depth-=❑.Eastern...,..,,,,�.,_.,Su face.Seal.lnstalied by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is } available within 200 feet.) Installation will serve: Residence Comm_`ial_ Other Number of living units: Number of beldr_oms � Character of soil to a depth of 3 feet:!4_. ' iLr�/ �� SEPTIC TANK ❑ Type/Mfg aft. .- W Water table depth 0 Y�r ,., .. F Capacity--Azop— No. Compartments PKG. TREATMENT PLT. ❑ €` J € �� Method of Disposal Distance to nearest: Well t ;'�-,�►.,-�-�.-�--�-- -- —#Foundtion�— Proparty Line 1s�L LEACHING LINE ❑ ?No. & Length of lines - Total length/size FILTER BEDe t Distance o nearest: :Well{ �� I I -A-6 Foundation Property Line SEEPAGE PITS ❑ J Depth + 'Size Number f t SUMPS ❑ 1pistance to nearest.+ Well Foundation 1 Property Line +{ DISPOSAL PONDS ❑ 4 ; # i I hereby certify that I have prepared this application grid;that the' work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health'District. i Home owner or licensed agent's signature certifies thefollowing: "I certify that in the performance of the work for which this pe' it issued"l efts//not employ any person in such manner as to become subject.to workman's compensation laws of California."Contractor's hiring or sb contracting signature certifies the following: "I certify that in the performance of.'the work for which this permit is issued, I shall em Io tion laws of California." { (j '' p Y persons subject to workman's compensa- The applicant must call f all required inspections. C omplete drawing on reverse side. Signed Title:_ � Date: , FOR DEPARTMENT USE ONLY ; 4 l Application Accepted by ! R '' q DateiA�� v� -Area Pit or Grout Inspection by t _ p I Y 7�� Date Final-lhs action b Date / , l � r Additional Comments: E ❑ Stk 466-6781 ❑ Lodi 369-3621 _ Manteca 823-7104 ❑TrAc0.835-6385 Applicant- Return aft copies to: Environmental'Hea'lth''Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE AMOUNT DUE I AMOUN�REMITTED CK -- _ „INFO _ } _CASH:ERE�CMVED BY _ DATE- PERMIT NO+ EH 43.24(REV.EH 14-28 . ',; _�iy/ - . . - •:_, � a